Provider Demographics
NPI:1558763771
Name:S PARK DDS INC
Entity Type:Organization
Organization Name:S PARK DDS INC
Other - Org Name:GROVE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SANGHO
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-714-7771
Mailing Address - Street 1:9727 ELK GROVE FLORIN ROAD SUITE 155
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:916-714-7771
Mailing Address - Fax:916-714-7779
Practice Address - Street 1:9727 ELK GROVE FLORIN RD STE 155
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-2291
Practice Address - Country:US
Practice Address - Phone:916-714-7771
Practice Address - Fax:916-714-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty